Takeaways from Health @ Seniors Today webinar, with Dr Darius Soonawalla

On Saturday, December 12, Seniors Today hosted Dr Darius. Soonawalla, leading orthopedic and joint replacement surgeon, who shed light on knee replacements for senior citizens. Dr Noor Gill captures the key takeaways from the session.

On Saturday, December 12, 2020, Seniors Today held yet its weekly  Health Live @ Seniors Today webinar with Dr Darius Soonawalla, leading Orthopaedic and Joint Replacement Surgeon attached to the Breach Candy, HN Reliance, Saifee and Jaslok Hospitals in Mumbai to discuss knee replacement surgery and care of the knees, especially for senior citizens. 

This was Dr Soonawalla’s second Health Live session.  in June 2020, he spoke about knee replacements and this is what he said: “Knee surgeries are fairly successful but it is important to understand when one should go for it. If the knees are handicapping you significantly then that would be the right time to go for a knee surgery. Consult your doctor to check if you require getting a knee surgery done.”

On December 12 he spoke on Knee Replacement Surgery in greater detail.

The session started with Dr. Soonawalla telling us about things have changed in pertinence to the Covid-19 pandemic since June 2020, when we last spoke with him. “We are not back to 100% normal yet. But people who earlier opted out of elective surgeries have now started going in to get their surgeries, so the numbers are picking up,” he said, adding: “And the good part, from a Covid point of view, is that at least now we know the treatment protocols, the systems are in place, so that part also seems to be under control. It is pretty safe to go to hospitals, for the simple reason, that the amount of precautions we take in the hospital are far more than one would take at home. And if you were to realise that most people who have contracted covid have gotten it from home.”

Essentially, knee replacement surgery is done as a procedure to alleviate pain in the knees. That is the primary reason why it is done. The reason why so many knee replacement surgeries are being done is because it is an extremely successful surgery and the recovery, now, is very rapid. If you have significant pain in your knees, it has a very successful outcome. The indication for the surgery is not that the patient is walking slowly or if he/ she has swelling in his/ her knees – for those concerns you need to find out what is causing the swelling and the change in pace and then move forward with the diagnosis and its treatment. 

There are various types of knee replacements, if one were to simplify and classify:

1. Partial knee replacement– only a small part of the knee is replaced
2. Total knee replacement– the complete knee, all 3 compartments of the knee are replaced.

The knee has three compartments, if only one compartment is affected, you can do a partial knee replacement and you certainly don’t need to do a total knee replacement. However if two or three compartments are affected then you need a total knee replacement (TKR) surgery.

The three compartments of the knee are:

1. Medial compartment which is on the inner side 
2. Lateral compartment which is on the outer side 
3. Patello-femoral compartment which is in the front, under the knee cap. 

– If a patient of Parkinson’s Disease wants to undergo the surgery and the Parkinson’s is well controlled, it is okay to undergo a knee replacement. If, however, the Parkinson’s is very advanced then the problem with undergoing the surgery is that your physiotherapy and recovery becomes very difficult. And a patient with advanced Parkinsonism does not recover from a knee replacement surgery as successfully as one would hope. So weigh- the degree of Parkinsonism and the severity of pain and then make your final decision.  

– If you have seasonal knee pain, for example in the winters, and you’re fine for the rest of the year, you should wait rather than jumping to a knee replacement surgery. But like it has been said before, the deciding factor remains the degree of pain and the degree of functional disability you are suffering from.

– If you have pain in the knee only when you bend it, for example, while driving and pressing on the clutch or the brakes, it could be because of early stages of osteoarthritis. The problem could be in the posterior part of your knee which is loaded when and hurts when it is put weight on. For that, what you can do is, go to a physiotherapist. There are certain exercises that can help you. It won’t cure your problem but it will help you pull on for a little longer. 

– If both your knees are equally bad and both of them are hurting you enough for you to consider surgery, then it is better to do a bilateral knee replacement surgery together because the physiological trauma to the patient is not doubled when you do both together. And you don’t have to go through the cycle of getting admitted, going through the surgery, going through the physiotherapy and recovery twice, you finish it off in one go. 

There are however times when you should only do one knee replacement surgery at a time and not both together. Some of which are:

1. If you have significant cardiac risk factors predisposing you to a higher risk of intra and post-operative complications. In that case you should not get a bilateral knee replacement surgery because that will put the body at a little more risk. And if you already have other comorbidities, it is not advisable. 
2. If your second knee is not as badly affected. Then you might as well wait for it to get bad, that could be after 5-7 years, and then you can go in for the surgery. 

As far as recovery after the surgery is concerned, hospitalisation is 2-3 days and it takes around six weeks to come back to normal functioning. After a knee replacement surgery, and after giving your knee sufficient time to recover and rest, it is okay to slow jog or fast walk. As long as you are not doing high intense exercises or work outs, it is fine. 

The implant has a limited shelf life, if you misuse the implant; you are going to affect the longevity of the implant. Sitting cross legged on the floor or sitting with your legs stretched out on the floor is perfectly alright, since that does not put a lot of load on your knees. However, if you sit squatting style or in a vajrasana, you are putting more load on the implant. While it is possible and many doctors allow their patients to sit that way, you need to remember that if you do that regularly, you are to some extent going to affect the life of your implant. You need to choose, would you rather avoid that and have your implant last longer or would you do that and face the consequences in the future. With the current implants, they tend to last for around 20 years.

So, if you lead an active life, and continue to do high impact activities, you’ll need to replace the implant sooner than later. If you are a basic senior citizen who goes for walks, indulges in leisure tennis, it should last for about 20-25 years.

There is a very small percentage of people who continue to have pain after the knee replacement surgery as well. But the percentage is very small and usually these people have very low level of pain. But by and large, after a knee replacement surgery you should be, for the most part of it, feel pain free. If after you’ve undergone your knee replacement surgery, you experience pain, before you go in for some more physiotherapy go to your doctor. He will most likely ask you to get and – ray done. He’ll take a look at the knee. You need to find out why do have a pain in your knee. Only after your doctor clears you and tells you that everything is okay o his end should you go in for the treatment he advises which can very well be physiotherapy.

Nothing in life is 100%, and so is the case with the success rates of any surgery including a knee replacement one. There are a few issues or complications that can persist after a knee replacement surgery

• Small group of people continue to have pain after a knee replacement. The medical fraternity has not quite been able to understand why that happens, it is related to the pain fibres in the knee and that is why some people continue to have some pain. 
• Post-operative infections in the implant are another big issue and concern.
• A clot in the veins of the leg is also a common post-operative complication.

These sorts of complications can happen with any surgery and the risk of these is very, very low. 

If you have early damage in the knees, Dr Soonawalla advises not to do sit-ups, instead do other exercises that would strengthen your legs. But, if you don’t have any damage in the knee, it is perfectly fine to do sit ups that are as long as you’re not overly heavy, because if you are, and you do sit ups, you can damage your knee further. 

The muscles around the knee are- the quadriceps and the hamstrings. Most exercises that people do involve strengthening the quadriceps. Walking backwards is one exercise that stimulates the hamstrings as well. It is a very good exercise. The only thing you should take care of is that you don’t fall. 

How to avoid the need for a knee replacement surgery:

If you are overweight-

 – Lose weight- this is the most important factor that helps determine the strength of your knees and the pain that they will undergo if not well taken care of. 

– Avoid any high impact activities like jogging, but you must do exercises which are non-impact, such as free style exercises- exercises from sitting at the edge of your bed or while sitting on a chair. Exercises that do not send any weight or load to your knees, for example, cycling

– Strengthen your knees

Certain yoga asanaas and exercises to alleviate and eliminate knee pain:

• The exercises you indulge in, whether they are at a gym, with a trainer, or yoga should focus on the exercises being non-impact, flexibility and knee strengthening exercises.
• Low impact or non-impact exercises include exercises that do not put a load on your knees. So avoid exercise that involves a lot of jumping around, or jogging. 
• Quadriceps curls, lying on the bed and cycling in the air are good exercises.
• Free style exercises- exercises from sitting at the edge of your bed or while sitting on a chair. 
• Exercises that do not send any weight or load to your knees, for example, cycling.
• Remain active
• Avoid activities like jogging or squats or climbing stairs, since they may aggravate your pain 
• When you go for a walk, wear some kind of a supportive gear for your knee like a knee cap, which might help you. 

When you do these exercises, you’re only strengthening the muscles and not reversing the osteoarthritis, it only strengthens the damaged knee.  Thus these can help delay the surgery but not completely by pass/avoid it altogether.

Try implementing these, and hopefully you can avoid a knee surgery. 

At 70 years of age, if you have a meniscus tear, Dr Soonawalla would not recommend a key-hole repair surgery. Because of the age, the tear is most likely to be degenerative, it is not a sports tear and degenerative tears do not do well after a key-hole surgery. It is for the younger individuals who have had a sporting injury leading to a meniscal tear that should consider this sort of surgery. 

Contrast fomentation therapy (is a form of treatment where the limb is immersed in hot, but not boiling water, followed by immediate immersion of the body in cold ice water) helps with knee pain.  But it is only a temporary fix, you will feel better for about 15 mins to half an hour, but you will need a more permanent solution to the problem. 

Osteoporosis is very different from osteoarthritis. You can do a knee replacement surgery for the latter but not for the former. So, if you are suffering from osteoporosis, make sure you’re taking adequate calcium, taking adequate Vit-D. You must remain active, you must walk. You should do exercises with weights because these weights strengthen your bones. And if you have a high degree of osteoporosis then you need to go on higher medications which your doctor will advice you. 

There are a lot of nutritional supplements that help with knee and joint pain. Glucosamine is one of these nutritional supplements. There is some evidence to show that these supplements give benefit. Is there any conclusive evidence? No. So, Dr Soonawalla cannot tell us with certainty if glucosamine will help definitively. It will have a transient effect and not a permanent one. 

All in all, Dr Soonawalla says knee replacement surgery is one of the most successful orthopaedic surgeries. 

If you want a consultation from Dr Darius Soonawalla, you can reach him at the following hospitals in South Mumbai: Breach Candy Hospital, Jaslok Hospital, HN Reliance Hospital and Saifee Hospital. For a tele-consult, he can be reached at Breach Candy Hospital: https://www.breachcandyhospital.org/index.php/orthopaedics-spec/dr-darius-soonawalla or his clinic at 022-23677779